A Response to Dr. Masters

Dear Dr. Masters: 

I appreciated reading your comments on the integrated primary care articles since they surface issues that seem to be on the minds of other psychologists as well. As I pondered your questions about integrated primary care, I wondered if your fundamental question is, "Should this be done?" or "What's the best way to do this?" Underlying the questions you raised seems to be a sense that the standard of care will not be as high in integrated care models. Are your misgivings primarily with the design of these emerging systems or with the motives you suspect are behind the changes?

If I were to rewrite our article, I'd start with a quote as I remember Dr. James Sabin making it several years ago, "The psychotherapist has a dual relationship--a fiduciary relationship with the client, and a relationship of stewardship with the payor." (If economists are to be believed, ultimately the employee and/or society is the payor, since whatever employers pay out in insurance premiums they withhold in terms of wages. To the extent these medical costs are tax deductible, society pays in terms of lost tax revenues).

Sabin's statement has two implications: First, we as behavioral health practitioners abdicated the stewardship role, and our abdication is implicitly reflected in our professional literature. Think for a moment of the proportion of journal articles which speak to the issue of being stewards. . .and then contrast that with the proportion which focus on our fiduciary role. I would venture that the preponderance relates to our fiduciary role. Second, if clinicians aren't willing to fulfill the role of steward (a historic stance, perhaps because we believe it's not a legitimate role), then this responsibility falls to others (now known generically as "managed care"). In large measure, we as providers are experiencing restrictions because we didn't act as good stewards when we had the opportunity. I would submit that we can't have it both ways - objecting to management of care, and yet not taking effective responsibility for it ourselves.

It is a given in current healthcare discussions that the growth of medical costs is unsustainable for us as a nation, particularly with the aging of the babyboomers. We are grappling with how to deal with limits in terms of what can or will be devoted to healthcare. Behavioral health clinicians and managers have potentially two general means of responsibly addressing these societal concerns while advocating for our share of the budget pie: We can be more intentional about how we will allocate limited resources (the 4-6% allocated to behavioral health) and/or we can try to demonstrate to decision makers that it is in their best interests to give us more. But how are either of these to happen?

In the article by Dr. Bruns and myself, we stopped short of actually suggesting where resources should be allocated. Rather, because psychologists typically are not looking at the bigger picture, we wanted to put the question on the table so that readers would consider it. Certainly there are a number of alternative approaches to prioritizing services, but evidence is needed to support such choices. To be frank, I was baffled that you found it "worrisome" that we would raise the question in order to promote reasoned discussion about such an important issue.

In order for behavioral health representatives to engage constructively with decision makers regarding budget issues, reasoned discourse using explicit assumptions is mandatory. Framed more adequately, the question might be stated, "Which allocation serves the greater public good?" I believe that it is when psychologists ignore these types of questions and focus solely on advocating for "individual rights" that they begin to lose allies in the budget debates. We as behavioral health providers will be much more effective in promoting our agenda if a balanced perspective is adopted which takes into account the healthcare system as a whole.

Having clarified the context for our remarks, I'd like to address several additional issues that you raise. The first has to do with triage. I'm indebted to Kirk Strosahl for pointing out that when people encounter the BMS, they tend to come with the "let's get to the point" mind set that characterizes primary care but which is less consistent with traditional psychotherapy. Such previous "socialization" assists in the triaging process although there will always be instances in which disclosure of extremely relevant material is delayed, whether in primary care or typical psychotherapy. However, the BMS may see members for several times, and then referral to specialty care is still possible.

You raised the question regarding deploying non-psychologists in integrated primary care positions. I believe that it is incumbent upon psychologists to demonstrate their superiority to others by the work they do. We need to be clear with decision makers regarding the particular treatments or diagnoses for which evidence establishes that we provide such exceptional care that it offsets the additional cost? If you were the decision maker regarding how to allocate the available budget for the most good to plan members, would you be hiring some MSWs for these positions? Might it not, in some cases, be the most responsible thing to do, given the evidence?

On the other hand, part of the Kaiser experience is that the contributions of the BMS psychologists are much more visible to the medical establishment than those of their counterparts in psychiatry because they are right at the heart of the care system. While some psychologists might lament that plight, we could instead use it to our advantage by building a business case for obtaining greater resources where they are meeting perceived needs, i.e., the "getting more of the pie" scenario suggested earlier.

You asked, "What happens if integrated primary care psychologists refer so many patients for additional psychological services that costs, at least initially, go up?" Within Kaiser, where the incentives are coordinated, such a situation would evoke additional strategizing to determine how patient flow can be better coordinated; given the budget, member needs, and the long term effects of the increase. If fact, a similar question is prompting us to revisit how care can be more effectively rendered for depression in order to implement process improvements. However, in a system where incentives are not coordinated, such as with behavioral health "carve-outs", affected parties face a much more contentious task.

You also asked, "Is it completely positive to have financial incentives coordinated under one organization?" If I understand correctly, you were concerned about the potential for abuse. Perhaps the question could be framed, "What are the advantages and disadvantages of coordinated financial incentives?" While one might acknowledge that the potential for abuse is everywhere, including integrated delivery systems, is there truly any greater danger here than with the status quo?

I would suggest that there is far less potential for abuse because, under a coordinated system, providing inadequate services in one sector typically creates additional utilization in other sectors, as well as greater utilization downstream. Thus there is a disincentive to withhold care where it should be most appropriately given. Moreover, there is considerable evidence emerging that integrated delivery systems offer the best opportunity for concerted health improvement campaigns such as disease management interventions because the incentives are aligned. Programs become increasingly feasible economically when additional care partners have something to gain from a particular health improvement strategy.

The BMS is a case in point. A primary care clinic, by itself, would not experience sufficient economic gains to justify employing a psychologist for such a position. However, when mental health and specialty care are factored in, the economic incentives are enhanced and the business case can be made (and a greater job market for psychologists is created). The result is better healthcare because services are now being rendered where they were not previously available and the consumer is given an additional benefit.

Turning to your comment about "the HMO's willingness to treat the inexpensive yet common problems to the exclusion of the more expensive and idiosyncratic disorders", I do not believe that there has been published empirical evidence to support that impression. What I do know from talking to medical directors making these kind of decisions, coupled with my experience within Kaiser, is that denials typically are for procedures for which evidence has shown little chance for success or those which are contrary to evidence-based best practices. In other words, the issue is not "this is expensive, therefore we won't do it", but "can the procedure and expense be justified, given the likelihood of success and guidelines for best practices?" In other words, is the public better served by this decision?

Consider the person with chronic back pain who is pressing to have surgery, yet an independent specialist estimates only a 5% chance of improvement with surgery. Given the costs, risks and inconvenience to the person (who would also need to go through an uncomfortable rehabilitation), should a health plan accede to the patient's demands for surgery? In a fee-for-service system where the surgeon gets paid to operate, the likelihood of surgery is greatly increased. In Kaiser's system, that person would be referred for evaluation in the chronic pain management program, an alternative much more in keeping with an evidence-based standard of care.

But let's address the issue of potentially shortchanging those with more severe psychopathology such as personality disorders. One rationale for using a BMS is that members with undiagnosed or untreated psychological disorders consume greater medical services. It would be self-defeating for a system to not treat these members because they would continue to drive up costs with inappropriate medical visits. Again, the criteria for treatment should be evidence- or outcomes-based: What interventions truly assist the member to function more effectively? Once more, the advantages of coordinating financial incentives play a role. A capitated mental health carveout does not have the same incentive as an integrated system to adequately treat the more severely impaired (and prevent unnecessary medical visits), whereas with an unmanaged fee-for-service benefit, treatment variability, both in approach and outcome, runs the gamut.

Thank you for inviting me to address the issues you have raised. While any system may have flaws or be abused, I've tried to show in multiple ways that the design of coordinating incentives and services promotes better care and actually lowers the potential for abuse. My hope is that, as health providers learn more about emerging systems as they are intended to work, their misgivings will diminish significantly. We as psychologists not only might assert that integrated primary care should be done, but that we have some evidence-based plans on the best way to do it.

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